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目的：探究鞘内注射地塞米松和静脉大剂量甲泼尼龙冲击治疗在创伤性脊髓损伤治疗中的安全性及疗效。方法：回顾性分析2015年9月至2023年3月华中科技大学同济医学院附属协和医院收治的43例创伤性脊髓损伤患者的临床资料，根据糖皮质激素给药方式不同，并按照损伤节段和损伤程度筛选及配对后，分别纳入采用鞘内注射地塞米松治疗的地塞米松组15例以及采用美国脊髓损伤协会（ASIA）推荐的静脉大剂量甲泼尼龙冲击治疗的甲泼尼龙组15例。所有患者均采用脊柱后路暴露椎板后行全椎板减压术，完成后路内固定植入。探查脊髓后，地塞米松组患者于蛛网膜下腔置入鞘内给药装置，术毕后经给药导管泵入地塞米松50 mg、30 min内泵完，第1次给药后24 h、48 h分别追加泵入地塞米松20 mg、30 min内泵完。采用截瘫指数、ASIA分级和ASIA运动评分（AMS）对纳入的创伤性脊髓损伤患者进行评价。记录两组患者在治疗过程及术后出现的不良反应。结果：两组患者获得24～110个月随访，平均随访（70.80±25.55）个月。地塞米松组15例患者中，5例ASIA A级无改善；1例B级恢复至C级，2例B级恢复至D级，1例B级恢复至E级；1例C级恢复至D级，2例C级恢复至E级；3例D级恢复至E级。甲泼尼龙组15例患者中，5例ASIA A级、2例B级、1例C级和1例D级无改善；1例B级恢复至C级，1例B级恢复至D级；1例C级恢复至D级，1例C级恢复至E级；2例D级恢复至E级。地塞米松组患者截瘫指数由3.00(2.00,4.00)改善至2.00(0.00,4.00),AMS由（50.67±28.60）分改善至85.00(58.00,100.00)分。甲泼尼龙组患者截瘫指数由3.00(2.00,4.00)改善至2.00(1.00,4.00),AMS由（53.07±29.47）分改善至60.00(50.00,96.00)分。两组患者术前、末次随访截瘫指数及差值比较，以及术前、末次随访AMS比较，差异均无统计学意义（P均>0.05）；地塞米松组患者术前与末次随访AMS差值大于甲泼尼龙组患者，差异有统计学意义（P<0.05）。地塞米松组中1例患者撤除鞘内导管后诉头晕，检查后考虑与鞘内注射药物无关，经保守治疗后第2日好转；所有患者脑脊液常规及生化检查均未发现阳性改变。甲泼尼龙组出现2例多重耐药菌引发的肺炎，1例消化道溃疡，经对症治疗后均好转。结论：创伤性脊髓损伤患者应用鞘内注射地塞米松治疗安全、有效，避免了全身应用糖皮质激素所带来的不良反应，对患者AMS的改善具有一定优势。
Abstract：Objective: To investigate the safety and efficacy of intrathecal dexamethasone injection compared with intravenous highdose methylprednisolone therapy in the treatment of traumatic spinal cord injury(TSCI). Methods: A retrospective analysis was conducted on the clinical data of 43 patients with TSCI admitted to Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from September 2015 to March 2023. Patients were selected and matched according to the route of glucocorticoid administration, injury level, and severity. Fifteen patients treated with intrathecal dexamethasone were included in the dexamethasone group, and 15 patients treated with intravenous high-dose methylprednisolone therapy according to the American Spinal Injury Association(ASIA) recommendations were included in the methylprednisolone group. All patients underwent posterior spinal exposure with total laminectomy decompression, followed by posterior spinal fixation. After spinal cord exploration, in the dexamethasone group, an intrathecal drug delivery device was implanted in the subarachnoid space. At the end of surgery, 50 mg of dexamethasone was infused via the delivery catheter over 30 minutes, After the first administration, 20 mg of dexamethasone was added 24 hours and 48 hours later, respectively, and complete within 30 minutes. Clinical outcomes were assessed using the Paraplegia Index, ASIA classification, and ASIA Motor Score(AMS). Adverse events during treatment and postoperatively were recorded. Results: The follow-up duration ranged from 24 to 110 months, with a mean of 70.80±25.55 months. In the dexamethasone group(n=15), five ASIA grad A patients showed no improvement; one grad B improved to C, two grad B improved to D, one grad B improved to E; one grad C improved to D, two grad C improved to E; three grad D improved to E. In the methylprednisolone group(n=15), five ASIA grad A, two B, one C, and one D patients showed no improvement; one grad B improved to C, one grad B improved to D; one grad C improved to D, one grad C improved to E; two grad D improved to E. In the dexamethasone group, the Paraplegia Index improved from 3.00(2.00, 4.00) to 2.00(0.00, 4.00), and the AMS from 50.67±28.60 to 85.00(58.00, 100.00). In the methylprednisolone group, the Paraplegia Index improved from 3.00(2.00, 4.00) to 2.00(1.00, 4.00), and the AMS improved from 53.07±29.47 to 60.00(50.00, 96.00). Comparisons between the two groups showed no statistically significant differences in the preoperative and final follow-up Paraplegia Index scores, their changes, as well as AMS scores(all P>0.05). However, the improvement in AMS from baseline to final follow-up was significantly greater in the dexamethasone group compared to the methylprednisolone group(P<0.05). One patient in the dexamethasone group experienced dizziness after catheter removal, which was considered unrelated to intrathecal medication and resolved on the second day with conservative treatment. No abnormalities were found in cerebrospinal fluid analysis or biochemical tests. In the methylprednisolone group, two patients developed pneumonia caused by multidrug-resistant bacteria, and one patient developed a gastrointestinal ulcer; all improved after symptomatic treatment. Conclusions: Intrathecal dexamethasone administration in patients with TSCI is safe and effective, avoids systemic glucocorticoid-related adverse effects, and offers a potential advantage in improving AMS.
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基本信息:
DOI：
中图分类号:R651.2
引用信息:
[1]薛沛然,卢宏伟,曾练等.鞘内注射地塞米松在创伤性脊髓损伤治疗中的临床应用[J].中华骨与关节外科杂志,2025,18(09):781-787.
基金信息:
国家自然科学基金（82072446,82572760）